Healthcare Provider Details

I. General information

NPI: 1982611349
Provider Name (Legal Business Name): MARIE ANSON-REBONG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 10/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2350 MCKEE ROAD STE 1
SAN JOSE CA
95116-1606
US

IV. Provider business mailing address

2350 MCKEE ROAD STE 1
SAN JOSE CA
95116-1606
US

V. Phone/Fax

Practice location:
  • Phone: 408-729-3232
  • Fax: 408-729-2165
Mailing address:
  • Phone: 408-729-3232
  • Fax: 408-729-2165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberA45814
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA45814
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: